America's Hospitals: In Danger or Bouncing Back?

Slide Presentation by Brad Prenney, M.S., M.P.A.

On November 20, 2002, Brad Prenney, M.S., M.P.A., made a presentation in a Web-assisted teleconference at Event 2, which was entitled "Emergency Department Overcrowding and Ambulance Diversion."

This is the text version of Mr. Prenney's slide presentation. Select to access the PowerPoint® slides (234 KB).

Emergency Department Overcrowding and Ambulance Diversion

Brad Prenney, M.S., M.P.A.
Deputy Director
Bureau of Health Quality Management
Massachusetts Department of Public Health

Slide 1

Statement of the Problem

• Ambulances are diverted away from the closest appropriate hospital because that hospital can not provide timely care.
• Diversion results in a delay in definitive care.
• Diversion is a public health problem that has worsened over the last several years.
• A related problem is the "boarding" of patients in the ED for extended periods of time while waiting for an inpatient bed.

Slide 2

Region IV Hospital Diversion Hours 2000-2002

This slide shows the number of hours hospitals in "Region IV" of Massachusetts spent on diversion status for the period of time between January 2000-August 2002.
The hours for 2000 by month were: January: 611; February: 345; March: 238; April: 330; May: 530; June: 558; July: 451; August: 498; September: 380; October: 396; November: 631; December: 677.

In 2001, the numbers of hours on diversion per month were: January: 1054; February: 691; March: 862; April: 874; May: 807; June: 849; July: 793; August: 1047; September: 761; October: 1050; November: 870; December: 843.

For 2002, the number of hours on diversion were: January: 1293; February: 1307; March: 859; April: 790; May: 736; June: 853; July: 818; August: 945.

Slide 3

Selected Highlights of Massachusetts Initiatives to Address Ambulance Diversion

• May 1999: First meeting of Ambulance Diversion Task Force.
• December 1999: Issuance of Best Practice Guidelines to Hospitals.
• December 2000: Issuance of Recommended Measures to Hospitals.
• February 2001: DPH Diversion Survey of Hospitals.
• June 2001: Publication of Issue Brief/Brandeis Forum.
• February 2002: Diversion Uniform Rules/Definitions Distributed.
• October 2002: Disaster/Gridlock Plan Developed.
• November 2002: Completion of Hospital Patient Flow Study.

Slide 4

Focus of Initiatives to Address Ambulance Diversion and ED Overcrowding

• Providing guidance to hospital and pre-hospital providers.
• Management of the problem.
• Understanding the factors contributing to the problem.

Slide 5

Diversion Measures within the Hospital (12/2000)

• Integrate written diversion policies within hospital disaster plans.
• Fast-track non-emergency patients.
• Staff all licensed beds during peak demand periods.
• Establish admissions plans for periods of ED overcrowding that:
  • Give priority to emergency patients.
  • Schedule surgeries in a way to maximize bed capacity.
  • Allow for rescheduling of elective surgeries to care for higher acuity patients.

Slide 6

Uniform Definitions/Rules Governing Ambulance Diversions

• Definitions for boarder, ED saturation, diversion.
• Honoring diversion requests.
• Exceptions to diversion.
• Immediate life-threatening situations.
• Patient preference/insistence/refusal.
• When contiguous hospitals request diversion.
• Selective diverting of ambulances.

Slide 7

Demand Factors

• Increase in volume of patients presenting to the ED (hospital closures, demographics—aging population), decreased access and/or satisfaction with community-based care.
• Increase in acuity.
• Increased diagnostic and treatment capability in the ED.
• Seasonal variation in communicable disease (i.e. flu).

Slide 8

Supply Side Factors

• Lack of staffed inpatient beds (financial constraints faced by hospitals, conversion to other uses, no longer staffing for the peaks).
• Shortage of staff (especially nursing, difficulty recruiting and retaining).
• Hospital closures (Massachusetts has lost about 1/3 of its hospitals over the last 20 years).

Slide 9

Internal Hospital Operations

• Factors that impede a hospital's ability to move patients efficiently through the system.
  1. Variability in scheduling OR/beds for elective and emergency surgery.
  2. Variability in admission and discharge processing.
  3. Variability between discharge and next admission to a bed.
• Lack of sufficient coordination and communication between services.

Slide 10

"While increasing use of the ED, especially for non-urgent needs, causes significant problems in patient flow, staff burn-out, and ED operations, we do not think that it is those who seek care for non-urgent issues who are responsible for the recent crisis of ambulance diversions. It is really the acutely ill patient who is waiting in the ED for a hospital bed who creates the bottleneck that leads to overcrowding, diversions, and essentially a breakdown in the entire system."

—Brent Asplin, M.D., M.P.H., Director of Research,
Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota

Slide 11

Current Initiatives to Address Ambulance Diversion and ED Overcrowding

• Quarterly meetings of Ambulance Diversion Task Force.
• Completion of patient flow study and dissemination of simulation model to hospitals.
• Development of disaster/gridlock plan.
• Continued Promotion of Best Practices.

Slide 12

DPH Gridlock Preparedness Saturation/Gridlock Disaster Response Plan

This slide provides a chart that can be used to create a response plan to three different "stages" of widespread hospital saturation. The three stages are listed as:

• Stage I: Multiple contiguous hospitals are saturated, on diversion, or requesting diversion at the same time. The EMS director believes public safety is in danger.
• Stage II: Stage I conditions persist, worsen or expand geographically despite Stage I interventions. The EMS director believes public safety remains jeopardized.
• Stage III: Multiple contiguous regions/geographies are in gridlock and the situation is deteriorating despite implementation of Stage II intervention. DPH Commissioner determines implementation based on risk to public safety.

Slide 13

Influenza and Pneumonia Hospital Admissions from Sept 1999-Sept 2000

The bar graph in this slide shows the number of hospital admissions due to influenza or pneumonia diagnoses (according to ICD-9 diagnoses). The number of cases starting in September 1999 is just below 500. This number reaches a peak in January 2000 with slightly under 5000 admissions. In February 2000, this number drops significantly to about 2500 and fluctuates around this number until September 2000 when admissions are down to about 1400.

Slide 14

Massachusetts Acute Care Hospital Discharges FFY 2000

This chart shows the number of patient discharges from acute care hospitals, according to payer type, with ER charges and without ER charges for fiscal year 2000. The payer type and percent of discharges with and without ER charges are as follows: Medicare/Medicare managed care had 58% discharges with ER charges, and 27% without. 13% of patients with HMOs were discharged with ER charges and 27% were discharged without. 10% of Medicaid/Medicaid Managed care patients were discharged with ER charges and 15% without. 7% Blue Shield/Blue Cross managed care discharges had ER charges and 15% did not. 4% of self pay/free care discharges had ER charges and 3% did not. 8% of all other payer types had ER charges and 13% did not.

Current as of June 2003

Internet Citation:

Emergency Department Overcrowding and Ambulance Diversion. Slide Presentation by Brad Prenney, at Web-Assisted Teleconference, "America's Hospitals: In Danger or Bouncing Back?" Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/hospital/prenneytxt.htm

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